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Human Resources for Health Strategy 2017-2021
Ministry of Health and Sanitation
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TABLE OF CONTENTS
LIST OF TABLES IV
LIST OF FIGURES IV
LIST OF ACRONYMS AND ABBREVIATIONS V
FOREWORD VI
REMARKS VII
1. EXECUTIVE SUMMARY 1
2. INTRODUCTION 5
2.1 PURPOSE AND HRHPOLICY DIRECTIONS 5
2.2 KEY STATISTICS 6
2.3 HEALTHCARE SYSTEM AND STRUCTURES 8
2.4 POLICY CONTEXT 9
3. METHODOLOGY 12
3.1 PROCESS AND PARTNER COORDINATION 12
3.2 DATA GENERATION AND ANALYSIS 13
3.3 INCORPORATING BEST PRACTICES AND LESSONS LEARNT 13
4. HRH SITUATIONAL ANALYSIS 14
4.2 PROGRESS SINCE 2011-2016HRHSTRATEGIC PLAN AND CURRENT HRHINITIATIVES 14
4.3 HEALTH WORKFORCE STATISTICS 14
4.4 HEALTH WORKER PRODUCTION 17
4.5 REGULATION 18
4.6 RECRUITMENT,MANAGEMENT AND RETENTION 18
4.7 PERFORMANCE MANAGEMENT 19
4.8 HEALTH WORKFORCE FINANCING 19
4.9 SUMMARY OF KEY CHALLENGES IDENTIFIED IN THE SITUATIONAL ANALYSIS 20 4.10 LESSONS LEARNED FROM INTERVENTIONS PREVIOUSLY ATTEMPTED TO ADDRESS HRH CHALLENGES 20
5. STRATEGY 23
5.1 THEORY OF CHANGE 23
5.2 STRATEGIES AND ACTIVITIES BY OBJECTIVE 25
OBJECTIVE 1:ENHANCE EVIDENCE-BASED HRH DECISION-MAKING FOR THE RATIONAL MANAGEMENT, PLANNING AND
FINANCING OF HEALTH WORKERS 25
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OBJECTIVE 2:IMPROVE HRH PRODUCTION TO ADDRESS NATIONAL HEALTH NEEDS AND MEET HEALTH PERSONNEL
REQUIREMENTS 29
OBJECTIVE 3:STRENGTHEN GOVERNANCE, LEADERSHIP AND MANAGEMENT FOR HRH 37 OBJECTIVE 4:ESTABLISH AND PROMOTE PARTNERSHIPS AMONG PUBLIC, PRIVATE AND NOT-FOR-PROFIT STAKEHOLDERS 42 OBJECTIVE 5:SUPPORT RESOURCE MOBILISATION AND ADVOCACY EFFORTS TO ENSURE THE IMPLEMENTATION OF THE HRH
POLICY AND STRATEGY 43
5.2 SUMMARY OF COSTS 44
5.3 CRITICAL ASSUMPTIONS AND RISKS 45
5.4 CROSS-CUTTING THEMES 47
REDUCING AND MANAGING THE UNSALARIED WORKFORCE 47
MONITORING AND REDUCING HEALTH WORKER ABSENTEEISM 48
IMPROVING RETENTION OF HEALTH WORKERS IN RURAL AREAS 49
6. MONITORING AND EVALUATION FRAMEWORK 51
7. REFERENCES 52
8. APPENDICES 54
APPENDIX 1:WORKPLAN AND BUDGET FOR YEAR 1 54
APPENDIX 2:COSTING METHODOLOGY AND KEY ASSUMPTIONS 65
OBJECTIVE 1 65
OBJECTIVE 2 68
OBJECTIVE 3 74
OBJECTIVE 4 AND OBJECTIVE 5 75
APPENDIX 3:COMPOSITION AND FOCUS AREAS OF TECHNICAL COMMITTEES 76
APPENDIX 4:INTERNATIONAL BEST PRACTICES AND EVIDENCE 77
IV
List of Tables
Table 1. Government healthcare facility count by level of care ... 9
Table 2. National plans and policies that informed the Sierra Leone HRH Strategic Plan 2017-2021 ... 11
Table 3. Lessons learned from previous HRH interventions ... 20
Table 4. Cost estimate of HRH Strategy 2017-2021 ... 44
Table 6. Draft workplan for the first year of the HRH Strategy ... 54
Table 7: Cost estimates for absorption of critical unsalaried workers ... 66
Table 8: Assumptions for costing of interventions under Objective 1 ... 68
Table 9. Assumptions for increased production by cadre ... 69
Table 10. Total cost estimates per cadre for increased production ... 70
Table 11: Assumptions for costing of interventions under Objective 2 ... 73
Table 12. Assumptions for costing of interventions under Objective 3 ... 74
Table 13. Composition and focus areas of Technical Committees ... 76
Table 14. Examples of HRH best practices from other countries ... 79
List of Figures Figure 1. Key health statistics for Sierra Leone ... 7
Figure 2. Facility-level staffing gaps for clinical cadres ... 15
Figure 3. Sierra Leone clinical health workforce density (per 10,000 population) ... 16
Figure 4. Urban versus rural distribution of the health workforce compared to population ... 17
Figure 5. Gender distribution of the health workforce by salary grade ... 17
Figure 6. HRH Strategic Plan 2017-2021 theory of change ... 24
Figure 7. MoHS clinical workforce projections 2017-2026 ... 71
Figure 8. Clinical MoHS wage bill projection for clinical cadres for 2017-2021... 72
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List of Acronyms and Abbreviations
BPEHS Basic Package for Essential Health Services CHA Community Health Assistant
CHC Community Health Centre CHO Community Health Officer CHP Community Health Post
CHW Community Health Worker
CMO Chief Medical Officer
CNMO Chief Nursing and Midwifery Officer DHMT District Health Management Team
DHRH Directorate of Human Resources for Health GoSL Government of Sierra Leone
HRH Human Resources for Health
HRMO Human Resource Management Office HSC Health Service Commission
iHRIS Integrated Human Resource Information System IPAS Individual Performance Appraisal System M&E Monitoring and Evaluation
MCH Maternal and Child Health MCHP Maternal and Child Health Post
MEST Ministry of Education, Science and Technology MoFED Ministry of Finance and Economic Development MoHS Ministry of Health and Sanitation
NPHA National Public Health Agency PHU Peripheral Health Unit
PRP President’s Recovery Priorities PSC Public Service Commission
SECHN State-Enrolled Community Health Nurse SLA Service Level Agreement
SRN State Registered Nurse TBA Traditional Birth Attendant TEC Tertiary Education Commission
Note: A currency exchange rate of USD 1 = SLL 7,200 has been assumed in this document.
VI Foreword
Health workers are a crucial pillar in a well-functioning resilient health system. The Ministry of Health and Sanitation is committed to promoting a resilient health workforce that will provide equitable, high quality health care to all Sierra Leoneans. This commitment is adequately captured in the Health Sector Recovery Plan 2015 -2020 and the Basic Package for Essential Health Services (2015).
The importance of strong human resources for health was demonstrated during the recent Ebola Virus Disease (EVD) outbreak from 2014 to 2015. Health workers across all cadres demonstrated bravery in combatting the outbreak, from the community health workers facilitating the dissemination of information and encouraging safe burial practices in their villages, to the medical staff in isolation units risking their lives to treat Ebola patients.
Unfortunately, as a result of these commendable efforts, over 250 health workers lost their lives to Ebola, exacerbating the already critical shortage of skilled health workers.
To continue rebuilding and improving the health system in Sierra Leone, the importance of human resources for health must be reflected in policies across the health sector. The Ministry of Health and Sanitation has already made substantial progress in this area over the past year, including (i) cleaning the payroll of inactive workers, (ii) operationalizing a comprehensive human resources information system; (iii) developing a training programme for Clinical Assistants – a mid-level cadre that will support the public health sector with clinical services in areas where doctors are limited, and (iv) developing programmes to train specialist medical doctors in country. The Ministry has also made headway in developing a comprehensive community health worker policy and strategy to enhance the health workforce’s ability to cover the hard-to- reach populations.
The launch of the Human Resources for Health Strategy for 2017-2021 will continue building on this progress by providing a roadmap through which the health workforce in Sierra Leone’s health sector will be further strengthened. The plan will address the most critical human resource for health challenges, across multiple intervention areas including training, regulation, financing and management.
The high levels of engagement, willingness to collaborate, and strong sense of government ownership projected by all parties involved in the strategy development process has been encouraging. The Ministry of Health and Sanitation will put the same qualities into the implementation of the strategy, in order to have the right health worker in the right place at the right time. I look forward to the support of all parties, from donors to implementing partners and the private sector, in the implementation of the 2017-2020 Human Resources for Health Strategy.
Honourable Dr Abu Bakarr Fofanah Minister of Health and Sanitation
VII Remarks
From the early conception of this strategy, we have stressed the importance that this will be an evidence-based and implementable plan that would allow both government and partners to understand the priority intervention areas in HRH and mobilise resources to address them accordingly.
The Human Resources for Health Strategy 2017-2021 has been developed in a series of technical committee meetings broken down by thematic area, including pre-service training, in-service training and regulation; financing and planning;
and management and governance. As co-chair of the Steering Committee, I have overseen progress of the strategy’s development and have witnessed collaborative discussion evolve into a structured, feasible and costed plan.
This document is thus a culmination of the input of a substantial group of national stakeholders, including ministries, departments and agencies across GoSL, numerous directorates and programmes of the Ministry of Health and Sanitation, the district health management teams, hospital leadership, training institutions, individual facility-based health workers, civil society groups, and the private sector, as well as international partners, NGOs and research institutions – in total amounting to over 260 individuals consulted throughout the process. I am grateful for the participation and dedication that these stakeholders have demonstrated.
These inputs will help to guide interventions in HRH to strengthen the Sierra Leone health workforce over the next five years.
Dr. Brima Kargbo (GOOR) Chief Medical Officer
Ministry of Health and Sanitation
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1. Executive Summary
Human Resources for Health are a crucial component in delivering high quality, affordable, and accessible health care services in every country. The ability for a country to meet its health goals depends largely on the knowledge, skills, motivation, and deployment of the people responsible for organising and delivering health care services. In the last few years, increasing attention has been paid to the development of health policies that guarantee better health outcomes in many countries.
However, a major drawback of these health policies has been their failure to address Human Resources for Health.
In Sierra Leone, persistent gaps in human resource capacity exist across all cadres, districts, and health care levels within its public-sector health workforce. These insufficient staffing levels have long been recognised as a key barrier to a resilient and responsive health system. The gap between staff needed and staff practicing has historically been most critical in higher cadres – particularly doctors and midwives. However, since the introduction of the Free Health Care Initiative in 2010, the health workforce has grown significantly – effectively doubling by 2011 (Oxford Policy Management, 2015).
This positive trend was, however, interrupted by the recent Ebola crisis which claimed the lives of at least 257 health workers in Sierra Leone and caused many others to temporarily leave the workforce.1 Though the health workforce has been growing overall recently, a significant number of the health workers are nearing the national retirement age of 60. Approximately 24% of all health workers are currently over the age of 50, while 394 health workers are already over 60.
The Government of Sierra Leone (GoSL) currently employs 9,910 health workers nationwide.2 This number includes all administrative and support staff, with 7,107 (72%) health professionals providing patient services.3 As of 2016, the government health workforce was distributed across 1,323 work stations, including hospitals, PHUs, clinics and administrative offices. Most health services are provided by public-sector health workers and very little data exists on the private-sector workforce (Ministry of Health and Sanitation, 2013).
The Directorate of Human Resources for Health (DHRH) led a highly consultative exercise to develop a national HRH Strategy to address these challenges affecting healthcare workers in Sierra Leone. It was conducted through three technical committees organised around different thematic areas. They were convened to review evidence on the status of the health workforce and develop activities to address
1Directorate for Human Resources for Health, MoHS
2This number excludes health workers removed from payroll as a result of the 2016 MoHS payroll audit and health workers granted early retirement from the civil service in June 2016. The number includes a small number of active health workers employed by other ministries than MoHS.
3Classification of health professionals as defined by the International Standard Classification of Occupations (ISCO); does not include Nursing Aide, Support Staff, or Administrative Staff cadres.
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priority challenges in the immediate, medium, and long term. The outcomes of their meetings were reviewed in a two-day consolidation workshop with prioritised challenges and strategies to address them.
This HRH Strategy 2017-2021 provides a framework to guide investments and activities to achieve the vision, goal, and objectives set forth in the recently revised HRH Policy 2017-2021. This strategy relies on a multi-sector and sector-wide approach; the objectives, strategies, and activities contained in the strategy consider a wide range of actors, including the Ministry of Education, Science, and Technology (MEST); Ministry of Finance and Economic Development (MoFED); regulatory and professional bodies;
for- and non-profit organisations; and faith-based organisations. It outlines the intervention areas, measurable targets, and a monitoring and evaluation (M&E) framework necessary to train, manage, and regulate an appropriate health workforce with the right skills in the right places to meet the country’s health needs. Through this HRH Strategy, GoSL aims to plan, produce, deploy, and maintain a resilient, highly-motivated health workforce that can contribute to national socioeconomic development by ensuring equitable, affordable, and high-quality health care services for the population of Sierra Leone.
Throughout the strategy process, the stakeholders prioritised quality improvements across the health workforce. Therefore this strategy differs from similar strategies in that it does not only primarily increase the number of workers, but focuses on improving quality before increasing the number of workers.
The intervention areas and activities that have been outlined to address the highlighted challenges are categorised under the five main strategic objectives defined in the HRH Policy 2016. They seek to:
1. Enhance evidence-based HRH decision-making for the rational management and financing of health workers
Under this strategic objective, MoHS aims to improve the collection, quality, use, and availability of health workforce data to ensure that evidence- and needs-based decisions are made by GoSL.
Fundamental to this strategic objective are the improvement of existing and the introduction of new MoHS information- and evidence-based systems including the integrated Human Resources Information System (iHRIS) and the District Health Information System (DHIS2). Information from these systems must be accessible to all levels of MoHS and relevant partners. Alongside the Government’s commitment to evidence-based decisions is the need to identify and advocate for the fiscal space necessary for financially sustainable health workforce development.
2. Improve HRH production to address national health needs and meet health personnel requirements
Under this strategic objective, MoHS aims to improve the quality and quantity of its health workers.
Immediate plans include investments in increasing production of professionals in midwifery and higher nursing along with strengthening the capacity of Community Health Workers (CHWs). During 2017,
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MoHS will also complement these investments with planning to determine how community-level cadres should evolve to respond to future primary care needs, which will then contribute to a long-term training plan. As the strategy development prioritised quality of training over quantity, strengthening clinical components of training will be a key focus. Further, the government is prioritising establishing systems for improved coordination of in-service training as well as clinical mentoring and supervision.
3. Strengthen governance, leadership, and management for HRH
Under this strategic objective, MoHS aims to strengthen its capacity to effectively plan and manage the national health workforce at the central and, especially, at the district level. Doing so requires investments in the leadership and management capacity at all levels of MoHS and in public health facilities – ensuring staff have the tools and knowledge necessary to make evidence-based decisions about the workforce. Additionally, critical investments should be made in the regulatory bodies and agencies that ensure the quality of health workforce training and service provision. Finally, these investments must be accompanied by communication among stakeholders in the health sector so that all actors have access to relevant, timely information to inform management and leadership decision- making.
4. Establish and promote partnerships among public, private and not-for-profit stakeholders
Under this strategic objective, MoHS aims to establish the cooperation and partnership from all sectors necessary to achieve the goal of this HRH Strategy. Across the government and regulatory agencies, inter-ministerial coordination is necessary to plan for, develop, and finance the national workforce.
Within MoHS, effective, community-based participation is necessary to improve health worker accountability and management. Partnerships with private-sector, non-governmental, and faith-based organisations in service delivery, education, and technology is paramount to resourcing and implementing the HRH Strategy successfully. Regional and global technical partnerships are also needed to assist the government to accomplish the strategic objectives laid out in the HRH Strategy.
5. Support resource mobilisation and advocacy efforts to ensure the implementation of the HRH Policy and Strategy
Under this strategic objective, MoHS aims to mobilise the resources necessary to fully implement the HRH Strategy. Sierra Leone requires additional investment to develop, manage, and maintain its health workforce to achieve the objectives in the HRH Strategy. MoHS will work with development partners to integrate improved data collection and analysis with budget development and prioritisation of funding.
For each of these strategic objectives, several operational activities have been identified. They have been broken down into operational activities in the immediate (2017), medium term (2018-2020), or long term (2021 and beyond). Performance indicators have also been established for measuring the performance of the programme and progress against the set objectives and targets as part of ongoing monitoring and evaluation of the overall strategic plan.
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The effective and successful implementation of this HRH Strategy will be highly dependent on the sustained focus, dedication, engagement, collaboration, and commitments of all the key stakeholders from government and private sectors, development partners, and staff of relevant ministries to stimulate and manage all the concerted efforts to produce the expected results.
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2. Introduction
The health workforce is a crucial pillar in every health sector and Sierra Leone has long suffered from health worker shortages. In the aftermath of the Ebola Virus Disease outbreak, the importance of investing in Sierra Leone’s health workforce is more evident than ever. Since then, the Ministry of Health and Sanitation has made significant efforts to rebuild the health sector, with a focus on improving maternal and child health. Strengthening human resources for health (HRH) has been a core component of this work and it is now a central theme in the plan that outlines the President’s Recovery Priorities (PRP) for the near future. These priorities include immediate investments to expand and strengthen the nursing and midwifery workforce, as well as the community health workforce, and to improve overall training quality. The PRP also identifies the need to ensure investments are being guided by a long-term vision for HRH in Sierra Leone. Hence, the Human Resources for Health Policy 2017-2021 and the Human Resources for Health Strategy 2017-2021 have been developed to provide that guidance and serve as building blocks in the larger effort to strengthen the health sector and improve health outcomes in Sierra Leone.
2.1 Purpose and HRH Policy Directions
This HRH Strategy provides a framework to guide investments and activities to achieve the vision, goal, and objectives set forth in the recently revised HRH Policy 2017-2021. The HRH Strategy relies on a multi-sector and sector-wide approach; the objectives, strategies, and activities contained herein consider a wide range of actors including the Ministry of Education, Science, and Technology (MEST), Ministry of Finance and Economic Development (MoFED), regulatory and professional bodies, for- and non-profit organisations, and faith-based organisations. It outlines the intervention areas, measurable targets, and a monitoring and evaluation (M&E) framework necessary to train, manage, and regulate an appropriate health workforce with the right skills in the right places to meet the country’s health needs.
The MoHS’ vision for HRH, defined in the HRH Policy (2016), sets the long-term, overall direction of national health workforce development and has served as the starting point for strategic discussions forming the HRH Strategy:
Consequently, the shorter-term goal which the Government of Sierra Leone aims to achieve through the HRH Strategy 2017-2021 is:
To plan, produce, deploy, and maintain a resilient, highly motivated health workforce that can contribute to national socioeconomic development by ensuring equitable, affordable and high- quality health care services for the population of Sierra Leone.
A resilient health workforce that is delivering cost-effective, evidence-based, and high-quality health care services that are equitable and accessible for the population of Sierra Leone by 2025.
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Further, a set of overarching strategic objectives have been defined in the HRH Policy 2017-2021 and are hence to be achieved through implementing this HRH Strategy 2017-2021.
2.2 Key Statistics
Despite significant gains in health outcomes since the end of the civil war in 2002, Sierra Leone has some of the worst health indicators in the world (see Figure 1) and ranks among the lowest, globally, for density of skilled birth attendants relative to the population.
The figure below outlines the health situation in Sierra Leone. It should be noted, however, that the health outcomes data reflects the situation before the recent Ebola epidemic and evidence suggests the outbreak had a negative impact on these figures (Evans, Goldstein, & Popova, 2015).
With the aim of improving health outcomes within the context of national and international commitments and policies, the strategic objectives of the HRH Policy are to:
1. Enhance evidence-based HRH decision-making for the rational management, planning, and financing of health workers
2. Improve HRH production to address national health needs and meet health personnel requirements
3. Strengthen governance, leadership, and management for HRH
4. Establish and promote partnerships among public, private, and not-for-profit stakeholders 5. Support resource mobilisation and advocacy efforts to ensure the implementation of the
HRH Policy and Strategy
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Figure 1. Key health statistics for Sierra Leone4
4 Data for life expectancy, disease burden and health outcomes from World Health Organization (2016) and UNAIDS (2015) and for Ebola outbreak from Centers for Disease Control and Prevention (2016).
Health worker to population ratios includes only government employees and is based on data from the 2016 MoHS payroll verification and the 2015 Population and Housing Census (Statistics Sierra Leone)
Total population in Sierra Leone: 7,092,113; Population of under-fives: 938,453 (13.2%)
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2.3 Healthcare System and Structures
Public sector health workers, governed by the Ministry of Health and Sanitation (MoHS), provide the majority of health services in Sierra Leone. The Free Health Care Initiative was introduced in 2010 to increase access to health services and reduce user fees. The Free Health Care Initiative provides free maternal and child health services to pregnant women, lactating mothers, and children under five years.
The government clinics also provide free malaria testing and treatment services to the entire population.
The 2015 Basic Package for Essential Health Services (BPEHS) defines level of care in relation to facility type, which is summarised in the remainder of this section (Ministry of Health and Sanitation, 2015). In Sierra Leone, Peripheral Health Units (PHUs) provide access to primary care and include the following facility types:
Maternal and Child Health Posts (MCHPs): Situated at the village level, MCHPs serve populations of less than 5,000. These units are intended to be staffed by Maternal and Child Health Aides (MCH Aides) who are trained to provide services including: antenatal care; supervised deliveries;
postnatal care; family planning; growth monitoring and promotion for under-five children;
immunization; health education; management of minor ailments and referral of cases to the next level.
Community Health Posts (CHPs): CHPs are situated in small towns serving populations between 5,000 and 10,000 and are staffed by Community Health Assistants (CHAs), State-Enrolled Community Health Nurses (SECHNs) and MCH Aides. They provide the same types of services provided at MCHPs, in addition to prevention and control of communicable diseases and rehabilitation.
Community Health Centres (CHCs): CHCs are located at chiefdom level and are responsible for supervising all CHPs and MCHPs within a chiefdom. They usually cover a population ranging from 10,000 to 20,000 and include the following staff: Community Health Officers (CHO), SECHNs, MCH Aides, laboratory staff, Epidemiological Disease Control Assistants and Environmental Health Assistants. Patients at CHCs can receive all aforementioned services provided at the CHP level, with the addition of environmental sanitation and basic laboratory services. Additionally, five CHCs per district are designated for basic emergency obstetric and newborn care.
Additionally, Community Health Workers (CHWs) provide primary health care services at the community level, while reporting to and being supervised by PHUs. However, CHWs are not currently part of the civil service. A geo-mapping conducted by MoHS and UNICEF identified 14,632 community-based
Number of peripheral health units includes only government CHCs, CHPs, and MCHPs, based on data from the MoHS Payroll Audit in February 2016.
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individuals working throughout the country (UNICEF & Ministry of Health and Sanitation, 2016). The Directorate of Primary Health Care and its partners launched a national CHW Policy in February 2017 and will launch a national CHW Strategy later in 2017.
For secondary care, 21 government hospitals provide technical support to the PHUs and serve as secondary-level referral facilities for primary health care. Secondary care facilities provide the following health services: outpatient services for referred cases from PHUs; primary care services for the local population within its immediate environs; inpatient (admission) health facilities; diagnostic services; and management of accidents and emergencies.
For tertiary care, three major government hospitals located in Freetown provide specialist health services including general surgery, internal medicine, obstetrics and gynaecology, and paediatrics. These tertiary hospitals are Connaught Hospital, Princess Christian Maternity Hospital, and Ola During Children’s Hospital.
The number of government healthcare facilities broken down by level of care is provided in Table 1.
Additionally, there are private hospitals and clinics that are at least partially staffed by government health workers, including Sierra Leone-China Friendship Hospital, Emergency Surgical Centre, and Aberdeen Women’s Centre; however, these private and public-private-partnership hospitals and PHUs have not been included in the facility count below.
Table 1. Government healthcare facility count by level of care5
Level of Care Facility Type Number
Tertiary Referral Hospital 3
Secondary Hospital (including regional referral
hospitals) 21
Primary Community Health Centre 229
Community Health Post 386
Maternal Child Health Post 559
Community Community Health Worker ~15,000
2.4 Policy Context
This document represents the result of extensive policy development and planning by the Government of Sierra Leone. In 2006, GoSL developed the first Human Resources for Health Policy (2006) to guide health workforce development. In 2012, in accordance with the National Health Sector Strategic Plan 2010-2015 (NHSSP), which provides a common strategic framework to guide interventions by all actors
5Facility information updated as of August 2016, based on facility-level data collection efforts conducted as part of the MoHS payroll audit in early 2016. It does not capture private- or faith-based clinics operating without government staff.
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at all levels of the health system, the HRH Policy was updated and informed the development of the first Human Resources for Health Strategic Plan 2012-2016. The HRH Policy and HRH Strategic Plan were complemented by the development of a comprehensive Scheme of Service (2010, 2015), which identified pay grades and career ladders for health workers. In this same time period, the Civil Service Code Regulations and Rules (2008, 2011) and the Health Service Commission Act (2011) were also established to set the regulatory and administrative framework for effectively managing the national health workforce. In 2011, the Government of Sierra Leone also established the National Health Compact to reaffirm the commitment of international partners to the national health priorities identified by MoHS.
In May 2014, in the wake of the devastating Ebola Virus Disease outbreak, MoHS revised the Basic Package of Essential Health Services (BPEHS) and developed both the Health Sector Recovery Plan 2015- 2020 (HSRP) as well as the President’s Recovery Priorities (2016) to guide the reconstruction of the health sector in the near- and long-term. The plans developed and revised in 2014 and 2015 recognise the crucial need for an appropriate health workforce to ensure resilient national health services.
Developing a national HRH Policy and Strategy was therefore identified as one of the key activities amongst the President’s Recovery Priorities. Consequently, in 2016, as MoHS worked to develop the HRH Strategy and revise the HRH Policy, MoHS also completed a process to review and update the Community Health Worker Policy (2012) and initiated the development the first Nursing and Midwifery Policy (2016). The costed HRH Strategy spanning 2017-2021 articulated in this document is informed by objectives and priorities stated in these policies and plans.
The current HRH Strategy has also been guided by the regional and global policies and best practices for health sector strengthening and health workforce development, including the Kampala Declaration and Agenda for Global Action on Health Workforce (2008), the Ouagadougou Declaration (2008), the World Health Organization Code of Practice on International Recruitment of Health Workers (2010) and the Sustainable Development Goals on Health and the Global Strategy on Human Resources for Health:
Workforce 2030.
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Table 2. National plans and policies that informed the Sierra Leone HRH Strategic Plan 2017-2021 Overall Health Policies
National Health Policy (2002)
National Health Compact (2011)
Agenda for Prosperity 2013-2018
Overall Cadre-Specific
Policies related to HRH
Human Resources for Health Policy (2006, 2012, 2016)
Civil Service Training Policy
National Community Health Worker Policy (2012)
National Community Health Worker Policy 2016-2020 (2016)
Strategies related to HRH
President’s Recovery Priorities (2016)
Health Sector Recovery Plan 2015-2020
National Health Sector Strategic Plan 2010-2015 (2010)
HRH Strategic Plan 2012-2016 (2012)
Basic Package of Essential Health Services (2015)
Nursing and Midwifery Policy (2016)
Community Health Worker Policy (2017)
Governance/Regulations related to HRH
HRH Scheme of Service (2006, 2013, 2015)
Civil Service Code, Regulations and Rules (2009, 2011)
Health Service Commission Act (2011)
The Medical and Dental Act (2007)
The Pharmacy and Drugs Act (2001)
Nurses and Midwives Act (1960; new Act not yet implemented developed in 2015)
Community Health Professionals Act (New Act not yet implemented, 2016)
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3. Methodology
3.1 Process and Partner Coordination
This document represents the culmination of a highly consultative process led by the Government of Sierra Leone that has considered input from more than 260 actors at every level of the health sector.
The strategic planning process was formally launched at the June 2016 HRH Summit in Freetown, Sierra Leone. During this summit, national and international participants convened to identify priority challenges to the health sector in Sierra Leone, review best practices for health workforce development and formalise the collaborative and evidence-driven strategy development process to follow.
In July 2016, an inter-ministerial Steering Committee was formed to provide oversight and guidance to the development of the HRH Strategy. The steering committee was co-chaired by the Chief Medical Officer and Permanent Secretary for Health and Sanitation, and included senior MoHS management, as well as senior leaders from the Health Service Commission, the Human Resources Management Office, the College of Medical and Allied Health Sciences, the Ministry of Finance and Economic Development, the Ministry of Education, Science, and Technology, and the Ministry of Local Government and Rural Development. A secretariat led by the Directorate of HRH, with support from the Clinton Health Access Initiative and the World Health Organization, provided process facilitation and continual analyses to support evidence-based decision-making.
From July through November 2016, three technical working groups – each organised around a different thematic area – convened to review evidence on the status of the health workforce and develop activities to address priority challenges in the short-, medium-, and long-term (see Appendix 3:
Composition and focus areas of Technical Committees for further detail). In September 2016, a two-day consolidation workshop was held for committees to review and agree upon the prioritised challenges and strategies. In November 2016, consultation workshops were held in each region (Makeni, Bo, and Kenema). Attendance included regional administrators, including hospital administrators, and fifteen participants from each district. Findings from technical working groups were then submitted to the inter-ministerial Steering Committee for inclusion in the HRH Strategy.
Starting in November 2016, the prioritised activities were consolidated into a single document and disseminated to key stakeholders for review and validation. The HRH Strategy 2017-2021 is slated for launch in early 2017.
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3.2 Data Generation and Analysis
In early 2016 MoHS completed a situation analysis of the national health workforce, informing the development of the Sierra Leone HRH Country Profile 2016 and revised HRH Strategy and to guide priority activities under the National Ebola Recovery Priorities for Sierra Leone 2015-2017. These analyses are summarised in HRH Situational Analysis. Key activities included:
Payroll Verification: The Directorate of HRH and partners worked to improve data quality and availability around the health workforce and complement activities related to the iHRIS exercise.
The activity resulted in a cleaned payroll dataset of all MoHS staff, a comprehensive database of the existing health workforce – including the unsalaried workforce – and updated guidelines and standards of practice to streamline and maintain payroll.
Human Resource Management Process Mapping: A comprehensive mapping exercise of HR policies – including hiring, leave, reassignment, and separation – was conducted by MoHS to assess opportunities to streamline HR processes and communicate the current standards of practice for all workers.
Health Workforce Pipeline Modeling and Cadre Mapping: Building on data collected through the payroll verification and from health-workforce training institutions in Sierra Leone, MoHS developed a forecasting model to assess the impact of potential workforce interventions and verify the training capacity of the health workforce sector in Sierra Leone.
3.3 Incorporating best practices and lessons learnt
To further ensure that the activities highlighted in this HRH Strategy are evidence-based, a desk review was conducted to identify and review interventions supporting the development of HRH to improve health outcomes – from within Sierra Leone as well as other countries. These best practices and lessons learned have helped to shape the activities in this strategy to fit the specific context of Sierra Leone.
Lessons learned from specific challenges previously encountered when implementing HRH interventions in Sierra Leone are described in the HRH Situational Analysis, whereas relevant international best practices are presented in Appendix 4: International best practices and evidence.
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4. HRH Situational Analysis
This section provides a brief introduction to core systems, processes, and challenges related to HRH in Sierra Leone and gives an overview of the current health workforce. A more detailed situational analysis with additional challenges and illustrative analyses can be found in the Sierra Leone HRH Country Profile 2016.
4.2 Progress since 2011-2016 HRH Strategic Plan and Current HRH Initiatives
In 2011, the national health workforce numbered just over 8,000.6 Over the course of the last strategic plan (HRH Strategic Plan 2012-2016), the workforce has grown by roughly 24% to over 9,900 health workers. Further, the MoHS’ Directorate of HRH has grown in capacity from five employees in 2011 to 26 in 2016, albeit only five employees have technical and professional backgrounds. This enhanced human resource capacity, combined with a renewed emphasis on HRH as part of the post-Ebola recovery process, has allowed the Directorate of HRH to lead MoHS in several activities aimed at building a more resilient health workforce. Most notably, the Directorate of HRH and its partners recently carried out a series of data collection activities to audit MoHS payroll, populate iHRIS, and model projected health workforce changes over time. This timely improvement in data quality and availability has facilitated development of a new, robust, evidence-based strategy to strengthen the health workforce in Sierra Leone.
4.3 Health Workforce Statistics
Insufficient staffing levels have long been recognised as a key barrier to a resilient and responsive health system in Sierra Leone. To demonstrate these staffing gaps, facility-level staffing norms defined in the BPEHS 2015 can be aggregated to national-level staffing requirements based on the number of government-owned facilities of each type, as counted as part of the 2016 payroll audit, and the average number of wards per hospital (see the HRH Country Profile for a full description of this methodology). As shown in Figure 2 below, the total number of health workers currently employed falls below this aggregated national-level staffing norm for every clinical cadre providing patient services. Staffing gaps are particularly significant for higher-skilled cadres such as doctors, specialist nurses, and midwives.
6 Includes health workers on government payroll
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Figure 2. Facility-level staffing gaps for clinical cadres 789
Government-employed health workers are highly concentrated in urban areas. Approximately 42% of the workforce currently employed by MoHS is active in Western Area and 10% in Bo district, where the country’s second largest city is located, while the remaining 47% of health workers are spread throughout the rest of the country. Even after accounting for relative district populations, the concentration of health workers in Freetown (Western Area Urban) remains noticeable. The density map below (Figure 3) shows the clinical health worker to population ratio by district, with the highest ratio being in Western Area Urban hospitals and PHUs, at 20.8 clinical health workers per 10,000 people (Statistics Sierra Leone, 2016).
7 Based on facility-level data collection efforts conducted as part of the MoHS payroll audit in early 2016
8 Includes GoSL-salaried health workers active in facilities only. In addition to these, there are many unsalaried health workers active in facilities but these are not accounted for in the figure (see 4.3 for more detail).
9 BPEHS facility- level staffing norms were aggregated into national norms by multiplying by the number of health workers required at each facility by the number facilities of each type
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Figure 3. Sierra Leone clinical health workforce density (per 10,000 population)10
In aggregate, the concentration of the health workforce in urban areas is significantly more prominent in comparison with the concentration of the total population in urban areas as shown below in Figure 4.
The concentration of health workers, particularly highly-skilled clinical staff, in urban areas corresponds with the general availability of advanced care, as all tertiary referral hospitals are located in Freetown and all secondary hospitals are in urban district capitals. Given the limited scope and efficiency of the current referral system, however, this distribution implies a disparity in access to health care between urban and rural settings.
10Includes all salaried health professional cadres and excludes administrative staff, support staff and nursing aides.
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Figure 4. Urban versus rural distribution of the health workforce compared to population11
Overall, the MoHS-employed health workforce is 62% female and 37% male. However, there is a clear pattern when looking at the gender distribution across the salary pay scale, which can be used to indicate a combination of skill level and seniority. Lower paid positions tend to be mainly female, while the highest paid positions are filled by males (Figure 5). This can be partially explained by the high percentage of lower-skilled female nurses in the workforce, while the most senior level MoHS positions are often filled by doctors – of which the majority are male.
Figure 5. Gender distribution of the health workforce by salary grade
4.4 Health Worker Production
There are currently 25 national health training institutions offering 56 different health programmes (clinical and non-clinical) from certificate to Master’s level. The SECHN certificate course is the largest programme, with 11 schools producing roughly 900 total new graduates per year while, in comparison,
11Health worker distribution is based on the urban/rural classification of the locality where found during the 2016 MoHS Payroll Audit; urban/rural distribution of the total population is from the 2004 Population and Housing Census by Statistics Sierra Leone.
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the single medical officer programme produces approximately 40 new graduates per year. Several new programmes have been introduced since 2011, including a nurse anesthesia programme and CHO specialist training programmes in emergency obstetrics and ophthalmology.
There has been no progress toward establishment of a nationally coordinated pre-service training plan since 2011. As a result, production often exceeds the government’s absorption capacity – particularly for lower cadre health workers. This has resulted in over 3,600 unsalaried clinical health workers providing patient services in government facilities despite not being part of the formal MoHS workforce.
4.5 Regulation
There have been few changes in regulation since 2011. Three health professional regulatory bodies – the Nurses and Midwives Board, the Medical and Dental Council, and the Pharmacy Board – are responsible for accrediting health training institutions and licensing health professionals belonging to the represented cadres. Unfortunately, health professional regulatory bodies remain under-resourced, meaning some programmes continue to operate without accreditation, and the licensing process is challenging to enforce and monitor. There are still no regulatory boards for health professionals outside of the nursing, midwifery, pharmacy, medical, and dental cadres.
However, two pieces of legislation with the potential to strengthen regulation of the health workforce are currently awaiting parliamentary approval as of February 2017. Firstly, implementing the Nurses and Midwives Act will result in creation of a Nurses and Midwifery Council with greater autonomy and ability to mobilise resources than the current Board. Secondly, the Community Health Professionals Act will create a regulatory board for CHOs and CHAs. This will be a significant achievement, as the government is currently unable to regulate the quality of community health professionals even though they provide direct patient care.
4.6 Recruitment, Management and Retention
The overall MoHS-employed health workforce has increased by eight percent since 2012.12 Responsibility for recruitment and deployment of health workers is currently split across several entities: the civil service’s Human Resource Management Office (HRMO), MoHS, and the Health Service Commission (HSC)--which was successfully operationalised in late 2012 and has since taken over health worker recruitment responsibilities from the Public Service Commission (PSC). However, no progress was made toward developing a national deployment policy during the implementation period of the previous HRH Strategic Plan (2012-2016).
12Based on MoHS payroll exports for June 2012 and June 2016
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Management of the health workforce remains highly centralised, with most decision-making power concentrated at the central-level MoHS, HSC, and HRMO. All leave approvals – including study leave, sick leave, annual leave, and maternity leave – must be authorised by the central-level MoHS and HRMO in addition to district and facility leadership. This often leads to significant delays in processing – causing health workers to go on leave without receiving official authorization.
Though national attrition data have historically been poor, one study reported that the Free Healthcare Initiative resulted in improved health worker motivation and retention since 2011 due to larger and more reliable salary payments (Witter, Wurie, & Bertone, The Free Health Care Initiative: how has it affected health workers in Sierra Leone?, 2014). Despite this, rural retention remains a challenge as the government has not been able to sustainably implement an effective remote area allowance scheme.
The Global Fund briefly funded a remote area allowance scheme, but the programme was discontinued in mid-2012 due to implementation challenges including insufficient personnel data management processes.
4.7 Performance Management
During the implementation period of the previous HRH Strategic Plan (2012-2016), MoHS worked with HRMO, PSC, and HSC to develop the Individual Performance Appraisal System (IPAS). IPAS provides a framework for employees and supervisors to structure work planning, setting of performance targets, and feedback and reporting twice a year. Three different IPAS forms exist for grades one through six, grades seven through ten, and grades eleven and up. While the Directorate of HRH has conducted preliminary IPAS trainings for health workers grade seven and above, the system has not yet been rolled out to MoHS employees nationwide.
4.8 Health Workforce Financing
At approximately SLL 148 billion (USD 20.5 million) per year as of 2016, the annual MoHS wage bill budget comprises 8.6% of the total Government of Sierra Leone wage bill budget. This is roughly a 60%
increase in the total MoHS wage bill since 2012, due to a combination of increased recruitment and annual increases in the salary scales.13 Donors have supported up to half of MoHS wage bill costs since 2010 – when the workforce doubled with the introduction of the Free Healthcare Initiative. Since 2010, both DFID and the Global Fund have contributed to the health worker wage bill as per the tripartite agreement with GoSL and they issue conditional reimbursements to the government when performance indicators are successfully achieved. GoSL has pre-financed all salary payments with no evidence of significant delays or non-payment. As of February 2017, there were no known workforce funding commitments from donors beyond 2017.
13Based on MoHS payroll exports for June 2012 and June 2016
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4.9 Summary of Key Challenges Identified in the Situational Analysis
The HRH situational analysis identifies many challenges (a comprehensive list is included in the Country Profile) that remain since the previous HRH Strategic Plan (2012-2016). These were starting points for strategic planning discussions leading up to this document and are summarised as follows:
Challenges in HRH Production and Regulation
Supply and demand of health worker production is not sufficiently coordinated to optimise resource allocation within the limited absorption capacity of GoSL.
Existing health professional regulatory bodies for nursing, midwifery, pharmacy, medical, and dental cadres are under-resourced, while no regulatory bodies currently exist for other health professionals.
Roughly half of health workers active in government facilities are unsalaried and, hence, not part of the formal health workforce – making it difficult to supervise and regulate these workers.
Challenges in HRH Financing and Planning
Financial sustainability planning is impeded by a lack of clarity around the future development of GoSL allocation to MoHS wage bill and a lack of funding commitments from external donors beyond 2017.
Health workforce planning and deployment decisions are not sufficiently evidence based.
Challenges in HRH Management and Governance
Health workforce management is highly centralised, resulting in long, bureaucratic processes and weak staff monitoring processes.
There is an overall lack of coordination and communication surrounding HRH matters between MoHS programmes and directorates, between GoSL bodies, and between government, donors, and other stakeholders.
Rural retention mechanisms are insufficient for motivating and retaining health workers deployed in rural areas.
4.10 Lessons learned from interventions previously attempted to address HRH challenges Table 3. Lessons learned from previous HRH interventions
Challenge Lesson learned
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Challenge Lesson learned
Overall strategy implementation:
Weak ownership and national engagement in previous HRH strategy
Limited implementation from previous HRH Strategy 2012-2016 Inadequate Human and financial resources available
Government ownership and engagement in strategy development is a pre-condition for successful implementation.
The HRH Strategy 2017-2021 has gone through a highly consultative process led by the Government of Sierra Leone with input from more than 260 actors, nationally and internationally, at every level of the health sector.
The strategy includes some initial costing and highlights a need for thorough financial planning and implementation monitoring with an M and E plan.
Coordinating health worker production:
Infeasible training plan in
previous HRH Strategy 2012-2016 with limited support across government
Close inter-ministerial collaboration (with MEST and MoFED) is necessary for production planning to be feasible, financially sustainable, and adequately matched to health needs.
With the involvement of all mentioned ministries in the HRH Strategy 2017-2021 development process, such collaboration has been initiated and is to be continued through the development of a health worker production plan (see activities under objective 3) and improved financial planning processes (objective 2).
Ensuring holistic health workforce investments that match health needs:
Lack of clarity about integration and complementarity between and across cadres – particularly at the community level
A holistic, systemic approach to workforce planning is necessary.
Consensus around the future composition of the health workforce at the community level was not achieved through the development of the HRH Strategy 2017-2021.
Before long-term production planning can commence, an assessment and recalibration of scopes of practice for all relevant cadres, particularly at the community level, is necessary (objective 3).
Absorbing additional staff onto government payroll:
Necessity to address and absorb the high number of so-called volunteers in the health workforce
Insufficient funds allocated to health worker salaries by MoFED.
There is continued need for closer continual dialogue between MoHS, HRMO, and MoFED to increase transparency and sustainability of workforce planning.
This is the main rationale for instituting the inter-ministerial Steering committee on payroll and financing (objective 2).
Moreover, there remains an identified the need for better planning with up-to-date workforce information to ensure effective resource allocation – a lesson that has led the current strategy to focus on workforce data generation, management, and use at the HRH Directorate level (objective 2).
Improving rural retention The current strategy therefore emphasises the strengthening of
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Challenge Lesson learned
through remote allowances:
2012 remote allowance policy was discontinued following improper attendance monitoring and data management
the attendance monitoring system (objective 1), along with efforts to improve data maintenance and use through iHRIS, before re- considering remote allowances.
Decentralisation efforts:
Limited HRH systems and reporting at the district level
There has not been sufficient formal links between central level HRH and the districts. This strategy focuses on establishing such links by introducing district and hospital HR officers and assistants – thereby improving communication streams between the different levels and enabling future de-concentration of HRH management (objective 1).
In-service training effectiveness:
Uncoordinated in-service training
MoHS has not had the necessary tools and capacity to coordinate the vast number of training providers. The current strategy acknowledges the need for a policy which defines protocols and guidelines for actors at all levels. Moreover, it identifies a need to develop coordination mechanisms and monitor in-service training participation (objective 3).
Attendance monitoring:
Challenges with the
implementation of attendance monitoring
Given that attendance monitoring is done at the facility, while subsequent analyses and actions are taken at the central level, the system’s effectiveness is contingent on close communication between management levels and prompt responsiveness to challenges.
This has proven difficult with the current technical infrastructure and lack of HRH management presence at the district level.
Further, discontinuing spot checks due to a lack of financing highlights the importance of financial sustainability planning in core HRH management activities.
Drawing from these lessons, the HRH Strategy 2017-2021 aims to leverage the district HR officers and assistants for improved attendance monitoring through i) improving communication at all levels, ii) ensuring any arising challenges can be dealt with in a timely manner and iii) introducing long-term sustainability in spot checking.
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5. Strategy
This section outlines intervention areas and activities designed to achieve each of the five strategic objectives defined in the HRH Policy. It also outlines overall implementation strategies, focusing on roles and responsibilities, needs for collaboration, and estimated costs. The timeline for implementation of activities is indicated as immediate term (2017), medium term (2018-2020), or long term (2021 and beyond). The strategy will be reviewed in 2018 to update workforce targets and incorporate further detail on activities currently planned for long term implementation.
Detailed activity planning is found in Appendix 1: Workplan and Budget for Year 1, while strategies for monitoring implementation progress and evaluating impact are found in the Monitoring and Evaluation framework.
5.1 Theory of Change
The activities included in this strategy are informed by a carefully designed theory of change which identifies the key goal, outcomes, intermediate outcomes, and objectives of implementing the HRH Strategy. The figure below provides an overview of the programme in its entirety.
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Figure 6. HRH Strategic Plan 2017-2021 Theory of Change
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5.2 Strategies and activities by objective
Objective 1: Enhance evidence-based HRH decision-making for the rational management, planning and financing of health workers
1.1 Strengthen MoHS systems for knowledge-based health workforce planning
Strengthening workforce data management and use is instrumental to enhancing needs-based planning and management. This intervention will be implemented in collaboration between the Directorate of HRH and DPPI and will focus on effective HRH information systems and their place in the overall health information systems architecture.
Key activity owners: Directorate of HRH Key collaborators: DPPI
Activities:
1.1.1 Strengthen national information systems relevant to health workforce planning and management (e.g.
iHRIS and DHIS)
Immediate term:
Define regular reports from iHRIS and processes for data maintenance Medium term:
Formalise plans for integrating payroll, attendance, iHRIS, and DHIS – building on previous work
Roll out iHRIS to districts and other HRH stakeholders such as regulatory boards, health training institutions, other directorates, and HSC
1.1.2 Generate and analyse evidence to inform select health workforce planning and management decisions
Immediate term:
Develop evidence base for the annual Manpower Planning Exercise – including use of iHRIS and other HRH data
1.1.3 Conduct HRH research studies to
Long term:
Develop a comprehensive labour market study to guide medium and long- Summary: Under this strategic objective, the MoHS aims to improve the collection, quality, use, and availability of health workforce data to ensure that evidence- and needs-based decisions are made by the Government of Sierra Leone. Fundamental to this strategic objective is the improvement of existing and introduction of new MoHS information- and evidence-based systems including iHRIS and DHIS. Information from these systems must be accessible to all levels of the MoHS and relevant partners. Alongside the Government of Sierra Leone’s commitment to evidence-based decisions is the need to identify and advocate for the fiscal space necessary for financially sustainable health workforce development.
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inform HRH policies and strategies
term financing and workforce planning strategies
Develop a private sector, non-governmental, and faith-based organisation workforce study to identify health workforce contribution to private service delivery (this study will also inform labour market study)
Cost estimate: USD 135,000 (SLL 973,000,000). Major costs include rolling out iHRIS to HRH stakeholders which will require technical support, e.g. to manage infrastructural needs and help define adequate access privileges.
1.2 Design and implement knowledge-based, results-focused health workforce management policies, strategies, and actions
This intervention aims to create the necessary policy environment for positive and sustainable HRH development. Discussions on key areas were initiated through the strategy development process. The question of potential absorption and future policies on unsalaried workers at government health facilities will be taken forward by the HRH strategy steering committee, while a technical working group has been formed with key stakeholders to develop health worker retention strategies. The Scheme of Service is to be revised under the leadership of HSC after the future composition of the community-level workforce has been reviewed as described under Objective 2.
Key activity owners: Directorate of HRH, HSC Key collaborators: Professional directorates
Activities:
1.2.1 Design and implement policies related to workforce management at all levels of MoHS;
central, district, and health facility
Immediate term:
Develop and implement a plan for absorption of critical unsalaried workers, i.e. workers trained as SRNs, midwives, or CHOs, and a policy on remaining unsalaried workers – including relevant management and monitoring procedures for enforcement
Medium term:
Develop and implement a deployment policy focusing on needs-based planning
Develop and implement a policy on rural retention inclusive of activities such as re-introducing the remote area allowance, establishing housing for health workers in remote areas, and advocating for free health care for health workers in remote areas; taking into account the management infrastructure improvements needed to ensure its effectiveness
1.2.2 Ensure MoHS is operating with adequately up-to- date policies on HRH governance
Medium term:
Update the Scheme of Service based on updated scopes of practice (see activity under Objective 2: Improve HRH production to address national health needs and meet health personnel requirements), with particular focus on community-level cadres
